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vI1Ir ' Y,�t,�/, 'ANNED <br /> -::, SANITARY PERMIT APPLICATION couN <br /> M'i�we M In accord with ILHR 83.05,Wis. Adm.Code <br /> l N <br /> _ STAT, IT YPEH�#�� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%X 11 Inches In size. Ch ck if revision to previous application <br /> -See reverse side for instructions for completing this application. STATE ILAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S - 3060 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> �iSM Et/aSlc /a, S T37 , N, R E(G <br /> PROPERTY OWN R'S MAILING ADDRESS LOT# / <br /> 2_ 11 WI h 0)' borer+ fir. J <br /> v, <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER C y <br /> it S yIJ Oro J <br /> CITY ` NEARES �or <br /> ie � rt <br /> II. TYPE OF BUILDING: (Check one) tate Owned O VILLAGE 121 IQWW . I- 1 0 <br /> ❑ Public ®1 or 2 Fam. Dwelling,#of bedrooms PAR EL AX NUMBERS) <br /> III. BUILDING USE: (If building type is public,check all that apply) �C) <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdo r Recreational Facility <br /> 3 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 12 [14 ❑ Church/School 8 [1 Mobile Home ParkService Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 El Off ice/Factory <br /> 13 ❑ Other Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.N New 2. ED Replacement 3. El Replacement of 4. ❑ Reconnection of 5'❑ Repa Exis ir oSaYstem <br /> System System Tank Only Existing System 9 <br /> B) ❑ A Sanitary Permit was previously issued. Permit# <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental <br /> Other <br /> D?11 ❑ Seepage Bed 21 Mound 30 El Specify Type 41 El Holding Tank <br /> J 42 PitPrivy <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 43 ❑ Vault Privy <br /> 13 ❑ Seepage Pit Pressure <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. E nCi RATE <br /> E 16. YSTEM ELEVt <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.)4 /S.0 -.7S 3-7 f- trZ 7• FeeVII. TANK CAPACITPrefab. Site Fibein allons Total #of Manufacturer's Name Concret Con- teel glas <br /> INFORMATION New istin Gallons Tanks structed <br /> Tanks Tanks <br /> e tic kor Holdin Tank DOD f <br /> ift Pum Tank/Si hon Chamber Q <br /> . RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for i stallation of the onsite sewage system shown on the attached pi ns. <br /> Plumber's Name(Prin Plum is Signature: N mps) <br /> MP/MPRSW No.: Business Phone Number: <br /> e(S v iL(fo <br /> P umberp's�A[ddress(Street,City,State,Zip Code): t r <br /> 7 l3 T s- <br /> IX. COUNTYIDEPARTMENT USE ONLY Issuing Si nature No to s <br /> ❑ Disa proved Sanitary Per Fee(Includes Grounawatar a e issued <br /> p Surchey Fee) <br /> Npproved ❑ Owner Given Initial W <br /> Adverse Det rminati n <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber ® — <br />